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Maxson R, Meshram P, Harris AB, Leland CR, Lu J, Niknahad A, Łukasiewicz P, Okeke L, McFarland EG. Infection following mini-open rotator cuff repair: a single surgeon experience. J Shoulder Elbow Surg 2025; 34:e205-e213. [PMID: 39384012 DOI: 10.1016/j.jse.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/26/2024] [Accepted: 08/03/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Surgical technique has been shown to influence risk of surgical site infection following rotator cuff repair (RCR). Few studies have reported the rate of infection associated with mini-open RCR. The goal of this study was to report the postoperative infection rate and risk factors for infection among patients undergoing RCR performed by a single surgeon using a modified mini-open technique. Our hypothesis was that the rate of infection after mini-open RCR would be lower than previously reported for this surgical approach. METHODS We retrospectively reviewed an institutional shoulder surgery database to identify patients who underwent mini-open RCR performed by 1 surgeon at an academic tertiary care institution between 2003 and 2020. Patient records were reviewed to determine which individuals returned within 3 months postoperatively with a superficial or deep surgical site infection requiring operative management. Patient demographics, preoperative clinical characteristics, intraoperative variables, microbiological findings, infection management, and clinical course after infection were recorded. Backward elimination multivariate regression was used to assess for significant risk factors for infection. RESULTS Of the 925 patients identified, 823 (89%) had at least 3 months of follow-up and were included for further analysis. A majority of the patients undergoing RCR were men (57%). The mean age was 58.4 ± 9.9 years, and the mean body mass index was 29.3 ± 5.9 kg/m2. Fourteen cases (1.7%) of postoperative surgical site infection were identified in 13 patients. Ten infections (1.2%) were superficial and 4 (0.49%) were deep. The most commonly identified organisms were Staphylococcus aureus and Cutibacterium acnes. Male sex (odds ratio [OR] 4.3, 95% CI 1.2-15.3) and diabetes mellitus (OR 3.9, 95% CI 1.2-12.6) were found to be associated with greater odds of infection. The RCR construct was found to be intact in all 10 patients with superficial infections and 2 of the 4 patients with deep infections. All infections were successfully treated with 1 round of surgical débridement and wound irrigation, and with 6 or fewer weeks of intravenous antibiotic therapy. All patients with postoperative infections recovered with no sequelae at a median final follow-up of 63.5 months (range, 3-215 months). CONCLUSIONS This single-surgeon series of a large patient cohort undergoing mini-open RCR over an 18-year period demonstrated a low overall infection rate of 1.7%. Only 4 infections were deep, which suggests that deep infection after mini-open RCR is uncommon and approximates infection rates seen with arthroscopic techniques.
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Affiliation(s)
- Ridge Maxson
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Prashant Meshram
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Andrew B Harris
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Christopher R Leland
- Harvard Combined Orthopedic Residency Program, Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jim Lu
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Ava Niknahad
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Piotr Łukasiewicz
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Laurence Okeke
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Edward G McFarland
- Division of Shoulder and Elbow Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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Lim JK, Kim JH, Park GT, Woo SH, Cho M, Kang SW. Efficacy of Light-Emitting Diode-Mediated Photobiomodulation in Tendon Healing in a Murine Model. Int J Mol Sci 2025; 26:2286. [PMID: 40076906 PMCID: PMC11899806 DOI: 10.3390/ijms26052286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2025] [Revised: 02/27/2025] [Accepted: 03/02/2025] [Indexed: 03/14/2025] Open
Abstract
The application of light-emitting diode (LED)-dependent photobiomodulation (PBM) in promoting post-tendon injury healing has been recently reported. Despite establishing a theoretical basis for ligament restoration through PBM, identifying effective LED wavelength combinations and ensuring safety in animal models remain unresolved challenges. In our previous study, we demonstrated that combined irradiation at 630 nm and 880 nm promotes cell proliferation and migration, which are critical processes during the early stage of tendon healing in human-derived tendon fibroblasts. Based on this, we hypothesized that 630/880 nm LED-based PBM might promote rapid healing during the initial phase of tendon healing, and we aimed to analyze the results after PBM treatment in a murine model. Migration kinetics were analyzed at two specific wavelengths: 630 and 880 nm. The Achilles tendon in the hind limbs of Balb/c mice was severed by Achilles tendon transection. Subsequently, the mice were randomized into LED non-irradiation and LED irradiation groups. Mice with intact tendons were employed as healthy controls. The total number of mice was 13 for the healthy and injured groups and 14 for the LED-irradiated injured group, and the data presented in this manuscript were obtained from one representative experiment (n = 4-5 per group). The wounds were LED-irradiated for 20 min daily for two days. Histological properties, tendon healing mediators, and inflammatory mediators were screened on day 14. The roundness of the nuclei and fiber structure, indicating the degree of infiltrated inflammatory cells and severity of fiber fragmentation, respectively, were lower in the LED irradiation group than in the LED non-irradiation group. Immunohistochemical analysis depicted an increase in tenocytes (SCX+ cells) and recovery of wounds with reduced fibrosis (lower collagen 3 and TGF-β1) in the LED irradiation group during healing; conversely, the LED non-irradiation group exhibited tissue fibrosis. Overall, the ratio of M2 macrophages to total macrophages in the LED irradiation group was higher than that in the injured group. LED-based PBM in the Achilles tendon rupture murine model facilitated a rapid restoration of histological and immunochemical outcomes. These findings suggest that LED-based PBM presents remarkable potential as an adjunct therapeutic approach for tendon healing and warrants further research to standardize various parameters to advance and establish it as a reliable treatment regimen.
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Affiliation(s)
- Jae Kyung Lim
- Department of Physiology, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (J.K.L.); (J.H.K.); (G.T.P.)
| | - Jae Ho Kim
- Department of Physiology, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (J.K.L.); (J.H.K.); (G.T.P.)
| | - Gyu Tae Park
- Department of Physiology, School of Medicine, Pusan National University, Yangsan 50612, Republic of Korea; (J.K.L.); (J.H.K.); (G.T.P.)
| | - Seung Hun Woo
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan 56012, Republic of Korea;
| | - Minkyoung Cho
- Department of Parasitology and Tropical Medicine, Institute of Medical Science, College of Medicine, Gyeongsang National University, Jinju 52727, Republic of Korea
| | - Suk Woong Kang
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan 56012, Republic of Korea;
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Wang KY, Kishan A, Abboud JA, Verma NN, Srikumaran U. Balloon Spacer Implant Is an "Intermediate Value" Innovation Relative to Partial Repair for Full-Thickness Massive Rotator Cuff Repairs: A Cost-Utility Analysis. Arthroscopy 2025; 41:635-644.e4. [PMID: 38925232 DOI: 10.1016/j.arthro.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/28/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To evaluate the cost-utility of a balloon spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCTs). METHODS A decision-analytic model comparing balloon spacer with PR was developed using data from a prospective, randomized, single-blinded, multicenter-controlled trial of 184 randomized patients. Our model was constructed on the basis of the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated on the basis of a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates. RESULTS The balloon spacer had an ICUR of $106,851 (95% confidence interval $96,317-$119,143) relative to PR for surgical treatment of MRCT. Across all patients, the balloon spacer was associated with greater 2-year QALY gain compared with PR (0.20 ± 0.02 for balloon spacer vs 0.18 ± 0.02 for PR), but with substantially greater total 2-year cost ($9,701 ± $939 for balloon spacer vs $6,315 ± $627 for PR). PR was associated with a positive incremental net monetary benefit of $1,802 (95% confidence interval $1,653-$1,951) over balloon spacer at the $50,000/QALY willingness-to-pay threshold. CONCLUSIONS Compared with PR, the balloon spacer is an "intermediate-value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 willingness-to-pay threshold. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.; Department of Orthopaedic Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, U.S.A
| | - Arman Kishan
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Joseph A Abboud
- Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush Medical College, Chicago, Illinois, U.S.A
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A..
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Rancu AL, Katsnelson BM, Sanchez JG, Winter AD, Vasudevan RS, Grauer JN. Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair. JSES Int 2025; 9:360-365. [PMID: 40182261 PMCID: PMC11962560 DOI: 10.1016/j.jseint.2024.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2025] Open
Abstract
Background Arthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and long-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. Methods Patients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology codes. The exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched in a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. 1-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. Results In total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354, respectively. Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (P < .0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (P < .0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and Conclusion Fibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in 1-year revisions.
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Affiliation(s)
- Albert L. Rancu
- Yale Department of Orthopaedics and Rehabilitation, New Haven, CT, USA
| | | | - Joshua G. Sanchez
- Yale Department of Orthopaedics and Rehabilitation, New Haven, CT, USA
| | - Adam D. Winter
- Yale Department of Orthopaedics and Rehabilitation, New Haven, CT, USA
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Sasanuma H, Takahashi T, Kawai S, Saitsu A, Kurashina W, Iijima Y, Saito T, Takeshita K. Morphological and histological evaluation of the tendon-bone junction in porcine shoulders to create a rotator cuff tear and repair model. J Orthop Sci 2024; 29:1521-1527. [PMID: 38007298 DOI: 10.1016/j.jos.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/30/2023] [Accepted: 11/14/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND This study aimed to morphologically and histologically examine whether pig is useful as models for rotator cuff tear (RCT). METHODS The morphology of the scapula and humerus bones was evaluated by taking X-ray and three-dimensional computed tomography (3D CT) scans of the right shoulders of five female pigs (age: 4 months). The rotator cuff (RC) footprint at the humeral insertion of these was observed and its shape was measured. Next, they underwent general anesthesia and an acute rotator cuff tear/rotator cuff repair (RCT/RCR) model was created using a deltoid split approach. Four weeks after surgery, the animals were euthanized, the shoulder joints were harvested, and the repaired RC was evaluated by hematoxylin and eosin staining and toluidine blue staining. RESULTS The scapula of the pig had a vestigial acromion, in contrast to that in humans. The supraspinatus and infraspinatus tendons were connected so as to overlap each other and attached to the postero-superior part of the greater tuberosity. These tendons were located extra-articularly, separate from the joint capsule. The average antero-posterior length of the foot print was 17.4 ± 0.7 mm on the medial margin and 19.1 ± 2.2 mm on the lateral margin. The maximum medial-to-lateral width of it was 5.1 ± 0.5 mm. In all RCT/RCR models at 4 weeks after surgery, the repaired RC compound tendon was visually confirmed to be continuous with the footprint. Histologically, it was confirmed that regeneration of the four-layer structure of the bone-tendon junction had occurred. CONCLUSION Porcine supraspinatus and infraspinatus attachment to the greater tuberosity have a structure similar to that of sheep and dogs, which is advantageous for creating the RCT/RCR model. It might be used for future in vivo studies of shoulder joint diseases. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE Pigs could potentially serve as a viable model for rotator cuff tears.
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Affiliation(s)
- Hideyuki Sasanuma
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Tsuneari Takahashi
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Shigeo Kawai
- Tochigi Medical Center Shimotsuga, Department of Diagnostic Pathology, 420-1, Ohira, Tochigi, 329-4498, Japan
| | - Akihiro Saitsu
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Wataru Kurashina
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Yuki Iijima
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Tomohiro Saito
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Katsushi Takeshita
- Jichi Medical University Hospital, Graduate School of Medicine, Department of Orthopaedics, 3311-1, Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Van Boxtel M, Cinquegrani E, Middleton A, Graf A, Hanley J, LoGiudice A. The impact of social deprivation on healthcare utilization patterns following rotator cuff repair. J Shoulder Elbow Surg 2024; 33:2421-2426. [PMID: 38552776 DOI: 10.1016/j.jse.2024.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/02/2024] [Accepted: 01/18/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized. METHODS This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared. RESULTS A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients. CONCLUSIONS Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.
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Affiliation(s)
- Matthew Van Boxtel
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | - Austin Middleton
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Graf
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jessica Hanley
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anthony LoGiudice
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Saavedra JP, Droppelmann G, Jorquera C, Feijoo F. Automated segmentation and classification of supraspinatus fatty infiltration in shoulder magnetic resonance image using a convolutional neural network. Front Med (Lausanne) 2024; 11:1416169. [PMID: 39290391 PMCID: PMC11405335 DOI: 10.3389/fmed.2024.1416169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 08/20/2024] [Indexed: 09/19/2024] Open
Abstract
Background Goutallier's fatty infiltration of the supraspinatus muscle is a critical condition in degenerative shoulder disorders. Deep learning research primarily uses manual segmentation and labeling to detect this condition. Employing unsupervised training with a hybrid framework of segmentation and classification could offer an efficient solution. Aim To develop and assess a two-step deep learning model for detecting the region of interest and categorizing the magnetic resonance image (MRI) supraspinatus muscle fatty infiltration according to Goutallier's scale. Materials and methods A retrospective study was performed from January 1, 2019 to September 20, 2020, using 900 MRI T2-weighted images with supraspinatus muscle fatty infiltration diagnoses. A model with two sequential neural networks was implemented and trained. The first sub-model automatically detects the region of interest using a U-Net model. The second sub-model performs a binary classification using the VGG-19 architecture. The model's performance was computed as the average of five-fold cross-validation processes. Loss, accuracy, Dice coefficient (CI. 95%), AU-ROC, sensitivity, and specificity (CI. 95%) were reported. Results Six hundred and six shoulders MRIs were analyzed. The Goutallier distribution was presented as follows: 0 (66.50%); 1 (18.81%); 2 (8.42%); 3 (3.96%); 4 (2.31%). Segmentation results demonstrate high levels of accuracy (0.9977 ± 0.0002) and Dice score (0.9441 ± 0.0031), while the classification model also results in high levels of accuracy (0.9731 ± 0.0230); sensitivity (0.9000 ± 0.0980); specificity (0.9788 ± 0.0257); and AUROC (0.9903 ± 0.0092). Conclusion The two-step training method proposed using a deep learning model demonstrated strong performance in segmentation and classification tasks.
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Affiliation(s)
- Juan Pablo Saavedra
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Guillermo Droppelmann
- Clínica MEDS, Santiago, Chile
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Carlos Jorquera
- Facultad de Ciencias, Escuela de Nutrición y Dietética, Universidad Mayor, Santiago, Chile
| | - Felipe Feijoo
- School of Industrial Engineering, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
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Fatoye F, Gebrye T, Nherera L, Trueman P. Adoption of a Societal Perspective in Economic Evaluations of Musculoskeletal Disorders: A Conceptual Paper. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2024; 12:216-223. [PMID: 39193540 PMCID: PMC11348208 DOI: 10.3390/jmahp12030018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 07/15/2024] [Accepted: 07/25/2024] [Indexed: 08/29/2024]
Abstract
Economic evaluations are used to compare the costs and consequences of healthcare interventions, including those for musculoskeletal (MSK) disorders, which are very common and a major source of morbidity and absence from work. Reimbursement decisions for interventions for MSK disorders by decision-makers rely on the findings of economic evaluations, the design and results of which depend largely on the perspective adopted. Despite methodological advancements in economic evaluations, there are no clear guidelines on the perspective to adopt. This paper explores the adoption of a societal perspective in economic evaluations of MSK disorders. Within health economics evaluations, the most commonly used perspectives include the payer perspective, the healthcare perspective, and the societal perspective. To facilitate optimal resource allocation decisions in order to reduce the significant economic burden of MSK disorders and improve the health outcomes of individuals with these disorders, all costs and benefits associated with interventions for them should be included. Thus, the societal perspective is arguably a preferable option to the others for economic evaluations of interventions for MSK disorders.
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Affiliation(s)
- Francis Fatoye
- Department of Health Professions, Faculty of Health and Education, Brooks Building I Manchester Metropolitan University, Manchester M15 6GX, UK;
| | - Tadesse Gebrye
- Department of Health Professions, Faculty of Health and Education, Brooks Building I Manchester Metropolitan University, Manchester M15 6GX, UK;
| | - Leo Nherera
- Smith + Nephew Inc., Global Market Access, 5600 Clearfork Main St, Fort Worth, TX 76109, USA; (L.N.); (P.T.)
| | - Paul Trueman
- Smith + Nephew Inc., Global Market Access, 5600 Clearfork Main St, Fort Worth, TX 76109, USA; (L.N.); (P.T.)
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Albarova-Corral I, Segovia-Burillo J, Malo-Urriés M, Ríos-Asín I, Asín J, Castillo-Mateo J, Gracia-Tabuenca Z, Morales-Hernández M. A New Quantitative Tool for the Ultrasonographic Assessment of Tendons: A Reliability and Validity Study on the Patellar Tendon. Diagnostics (Basel) 2024; 14:1067. [PMID: 38893594 PMCID: PMC11171978 DOI: 10.3390/diagnostics14111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/21/2024] Open
Abstract
Ultrasound is widely used for tendon assessment due to its safety, affordability, and portability, but its subjective nature poses challenges. This study aimed to develop a new quantitative analysis tool based on artificial intelligence to identify statistical patterns of healthy and pathological tendons. Furthermore, we aimed to validate this new tool by comparing it to experts' subjective assessments. A pilot database including healthy controls and patients with patellar tendinopathy was constructed, involving 14 participants with asymptomatic (n = 7) and symptomatic (n = 7) patellar tendons. Ultrasonographic images were assessed twice, utilizing both the new quantitative tool and the subjective scoring method applied by an expert across five regions of interest. The database contained 61 variables per image. The robustness of the clinical and quantitative assessments was tested via reliability analyses. Lastly, the prediction accuracy of the quantitative features was tested via cross-validated generalized linear mixed-effects logistic regressions. These analyses showed high reliability for quantitative variables related to "Bone" and "Quality", with ICCs above 0.75. The ICCs for "Edges" and "Thickness" varied but mostly exceeded 0.75. The results of this study show that certain quantitative variables are capable of predicting an expert's subjective assessment with generally high cross-validated AUC scores. A new quantitative tool for the ultrasonographic assessment of the tendon was designed. This system is shown to be a reliable and valid method for evaluating the patellar tendon structure.
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Affiliation(s)
- Isabel Albarova-Corral
- PhysiUZerapy Health Sciences Research Group, Department of Physiatry and Nursing, University of Zaragoza, 50009 Zaragoza, Spain
| | - José Segovia-Burillo
- Fluid Mechanics, Instituto de Investigación en Ingeniería de Aragón (I3A), University of Zaragoza, 50018 Zaragoza, Spain
| | - Miguel Malo-Urriés
- PhysiUZerapy Health Sciences Research Group, Department of Physiatry and Nursing, University of Zaragoza, 50009 Zaragoza, Spain
| | - Izarbe Ríos-Asín
- PhysiUZerapy Health Sciences Research Group, Department of Physiatry and Nursing, University of Zaragoza, 50009 Zaragoza, Spain
| | - Jesús Asín
- Modelos Estocásticos Research Group, Department of Statistical Methods, University of Zaragoza, 50009 Zaragoza, Spain
| | - Jorge Castillo-Mateo
- Modelos Estocásticos Research Group, Department of Statistical Methods, University of Zaragoza, 50009 Zaragoza, Spain
| | - Zeus Gracia-Tabuenca
- Modelos Estocásticos Research Group, Department of Statistical Methods, University of Zaragoza, 50009 Zaragoza, Spain
| | - Mario Morales-Hernández
- Fluid Mechanics, Instituto de Investigación en Ingeniería de Aragón (I3A), University of Zaragoza, 50018 Zaragoza, Spain
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Ma S, Zheng S, Li D, Hu W, Wang L. Melt Electrowriting Combined with Fused Deposition Modeling Printing for the Fabrication of Three-Dimensional Biomimetic Scaffolds for Osteotendinous Junction Regeneration. Int J Nanomedicine 2024; 19:3275-3293. [PMID: 38601348 PMCID: PMC11005997 DOI: 10.2147/ijn.s449952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/28/2024] [Indexed: 04/12/2024] Open
Abstract
Purpose This study aims to explore a novel scaffold for osteotendinous junction regeneration and to preliminarily verify its osteogenic and tenogenic abilities in vitro. Methods A polycaprolactone (PCL) scaffold with aligned and orthogonal fibers was created using melt electrowriting (MEW) and fused deposition modeling (FDM). The scaffold was coated with Type I collagen, and hydroxyapatite was carefully added to separate the regions intended for bone and tendon regeneration, before being rolled into a cylindrical shape. Human adipose-derived stem cells (hADSCs) were seeded to evaluate viability and differentiation. Scaffold characterization was performed with Scanning Electron Microscope (SEM). Osteogenesis was assessed by alkaline phosphatase (ALP) and Alizarin red staining, while immunostaining and transcription-quantitative polymerase chain reaction (RT-qPCR) evaluated osteogenic and tendogenic markers. Results Scaffolds were developed in four variations: aligned (A), collagen-coated aligned (A+C), orthogonal (O), and mineral-coated orthogonal (O+M). SEM analysis confirmed surface morphology and energy-dispersive X-ray spectroscopy (EDS) verified mineral coating on O+M types. Hydrophilicity and mechanical properties were optimized in modified scaffolds, with A+C showing increased tensile strength and O+M improved in compression. hADSCs demonstrated good viability and morphology across scaffolds, withO+M scaffolds showing higher cell proliferation and osteogenic potential, and A and A+C scaffolds supporting tenogenic differentiation. Conclusion This study confirms the potential of a novel PCL scaffold with distinct regions for osteogenic and tenogenic differentiation, supporting the regeneration of osteotendinous junctions in vitro.
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Affiliation(s)
- Shengshan Ma
- Department of Orthopedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
- Department of Sports Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, Jiangsu, People’s Republic of China
| | - Suyang Zheng
- Department of Orthopedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
| | - Dong Li
- Department of Trauma Center, The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University, Changzhou, Jiangsu, People’s Republic of China
| | - Wenhao Hu
- Department of Orthopedic Surgery, The Affiliated Huai’an No.1 People’s Hospital of Nanjing Medical University, Huai’an, Jiangsu, People’s Republic of China
| | - Liming Wang
- Department of Orthopedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China
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Ho JC, Derwin K. Is 3D Quantitative MRI the Next Tool to Evaluate Rotator Cuff Musculature and Other Muscle Pathology?: Commentary on an article by Junjie Xu, MD, PhD, et al.: "Longitudinal Changes in Overall 3D Supraspinatus Muscle Volume and Intramuscular Fatty Infiltration After Arthroscopic Rotator Cuff Repair". J Bone Joint Surg Am 2024; 106:e6. [PMID: 38323991 DOI: 10.2106/jbjs.23.01313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Jason C Ho
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kathleen Derwin
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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12
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Liu X, Zhou M, Tan J, Ma L, Tang H, He G, Tao X, Guo L, Kang X, Tang K, Bian X. Inhibition of CX3CL1 by treadmill training prevents osteoclast-induced fibrocartilage complex resorption during TBI healing. Front Immunol 2024; 14:1295163. [PMID: 38283363 PMCID: PMC10811130 DOI: 10.3389/fimmu.2023.1295163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/21/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction The healing of tendon-bone injuries is very difficult, often resulting in poor biomechanical performance and unsatisfactory functional recovery. The tendon-bone insertion has a complex four distinct layers structure, and previous studies have often focused on promoting the regeneration of the fibrocartilage layer, neglecting the role of its bone end repair in tendon-bone healing. This study focuses on the role of treadmill training in promoting bone regeneration at the tendon-bone insertion and its related mechanisms. Methods After establishing the tendon-bone insertion injury model, the effect of treadmill training on tendon-bone healing was verified by Micro CT and HE staining; then the effect of CX3CL1 on osteoclast differentiation was verified by TRAP staining and cell culture; and finally the functional recovery of the mice was verified by biomechanical testing and behavioral test. Results Treadmill training suppresses the secretion of CX3CL1 and inhibits the differentiation of local osteoclasts after tendon-bone injury, ultimately reducing osteolysis and promoting tendon bone healing. Discussion Our research has found the interaction between treadmill training and the CX3CL1-C3CR1 axis, providing a certain theoretical basis for rehabilitation training.
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Affiliation(s)
- Xiao Liu
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Mei Zhou
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jindong Tan
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Lin Ma
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hong Tang
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Gang He
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xu Tao
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Lin Guo
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xia Kang
- Pancreatic Injury and Repair Key Laboratory of Sichuan Province, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Kanglai Tang
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xuting Bian
- Department of Sports Medicine, Southwest Hospital, Army Medical University, Chongqing, China
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Smith JT, Pill SG, Eggert KA, Brignull CG, Adams KJ, Wyland DJ, Tolan SJ, Thigpen CA, Kissenberth MJ. Corticosteroid injection prior to surgery had no effect on 2-year outcomes following arthroscopic rotator cuff repair. JSES Int 2024; 8:75-79. [PMID: 38312263 PMCID: PMC10837736 DOI: 10.1016/j.jseint.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Corticosteroid injections (CSIs) can be an effective nonsurgical treatment for patients with rotator cuff tears. Recent large database studies have raised concern that CSI may result in a higher reoperation rate, increased infection risk, and worse outcome after arthroscopic rotator cuff repair (ARCR). The purpose of this study was to evaluate the reoperation rate, incidence of postoperative infection, and two-year outcomes of patients undergoing ARCR with and without the use of preoperative CSI. Methods An institutional database generated from fellowship-trained orthopedic sports surgeons was retrospectively queried for patients who underwent ARCR with a minimum of two-year follow-up. Inclusion criteria consisted of 1) primary full-thickness rotator cuff tear and 2) preoperative and minimum two-year patient-reported outcome measures (PROMs). Of the 219 patients identified, 134 patients had preoperative subacromial CSI administered within one year of ARCR. Reoperation rate, number of injections, Visual Analog Scale, American Shoulder and Elbow Surgeons Score, Single Assessment Numeric Evaluation, and Veterans Rand 12-Item Health Survey Physical Component Score/Mental Component Score were compared between groups at six months, one year, and two years. Chi-square and t-tests were used to compare baseline differences, postoperative infections, and reoperations. A repeated measures Analyses of Covariance was used to measure differences between PROMs at each time point. Simple Analyses of Covariance were used for the two-year sub-analyses for patients receiving CSI within 90 days of surgery and if multiple preoperative CSI had been given (α ≤ 0.05). Results There were no significant demographic differences between groups (P > .05). Preoperative use of subacromial CSI within one year prior to ARCR did not increase reoperation rate (P = .85) or impact PROMs at any timepoint. There were two reoperations during the study period in the CSI group (2 lysis of adhesions). No infections occurred in either cohort. No differences were found if injections were performed within 90 days of surgery or if more than one CSI was administered within the year prior to surgery (P > .05). Conclusion Our results show that preoperative CSI prior to primary ARCR did not increase risk of reoperation, infection, or influence PROMs with a minimum follow-up of 2 years.
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Affiliation(s)
- Justin T. Smith
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Stephan G. Pill
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | | | | | - Kyle J. Adams
- Department of Orthopedics, Prisma Health Upstate, Greenville, SC, USA
| | - Douglas J. Wyland
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Stefan J. Tolan
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Charles A. Thigpen
- ATI Physical Therapy, Greenville, SC, USA
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
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Yu C, Feng S, Li Y, Chen J. Application of Nondegradable Synthetic Materials for Tendon and Ligament Injury. Macromol Biosci 2023; 23:e2300259. [PMID: 37440424 DOI: 10.1002/mabi.202300259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
Tendon and ligament injuries, prevalent requiring surgical intervention, significantly impact joint stability and function. Owing to excellent mechanical properties and biochemical stability, Nondegradable synthetic materials, including polyethylene terephthalate (PET) and polytetrafluoroethylene (PTFE), have demonstrated significant potential in the treatment of tendon and ligament injuries. These above materials offer substantial mechanical support, joint mobility, and tissue healing promotion of the shoulder, knee, and ankle joint. This review conclude the latest development and application of nondegradable materials such as artificial patches and ligaments in tendon and ligament injuries including rotator cuff tears (RCTs), anterior cruciate ligament (ACL) injuries, and Achilles tendon ruptures.
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Affiliation(s)
- Chengxuan Yu
- Department of Sports Medicine, Huashan Hospital, Fudan University; Sports Medicine Institute of Fudan University, Shanghai, 200040, China
| | - Sijia Feng
- Department of Sports Medicine, Huashan Hospital, Fudan University; Sports Medicine Institute of Fudan University, Shanghai, 200040, China
| | - Yunxia Li
- Department of Sports Medicine, Huashan Hospital, Fudan University; Sports Medicine Institute of Fudan University, Shanghai, 200040, China
| | - Jun Chen
- Department of Sports Medicine, Huashan Hospital, Fudan University; Sports Medicine Institute of Fudan University, Shanghai, 200040, China
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15
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Rognoni C, Nherera LM, Garofalo R, Guerra E, Longo UG, Taverna E, Tarricone R. Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy. Adv Ther 2023; 40:5271-5284. [PMID: 37759150 PMCID: PMC10611596 DOI: 10.1007/s12325-023-02686-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy. METHODS A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy. RESULTS Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results. CONCLUSION In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.
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Affiliation(s)
- Carla Rognoni
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy.
| | | | | | | | - Umile Giuseppe Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Bocconi University, Via Sarfatti 10, 20136, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
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Nasr AJ, Pierson CJ, Tzen YT, Khazzam M, Jain NB, Lin YS. Emerging Role of Quantitative Ultrasound-Based Imaging Techniques for Characterizing Rotator Cuff Tears: A Scoping Review. Diagnostics (Basel) 2023; 13:2011. [PMID: 37370906 PMCID: PMC10297292 DOI: 10.3390/diagnostics13122011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Rotator cuff myosteatosis following cuff tears is very common and one of the most important prognostic factors in clinical management. Quantitative ultrasound-based imaging techniques (QUBIT) are frequently used along with magnetic resonance imaging (MRI) to evaluate rotator cuff fatty degeneration. However, the examination of rotator cuff tissue integrity by QUBIT is lacking a standardized imaging protocol and procedural methodologies. In this scoping review, we synthesized the current state of QUBIT against the reference imaging modalities in patients with rotator cuff tears. The literature search was extracted from 963 studies, with 22 studies included in the final review in accordance with the preferred reporting items for systematic reviews and meta-analyses extensions for scoping reviews. The selected studies included human participants and focused on measuring at least one prognostic or diagnostic factor using ultrasonography-based imaging with reference to MRI. The findings suggest both conventional B-mode ultrasound and shear wave elastography imaging were comparable to MRI-based imaging techniques for the evaluation of fatty infiltration and rotator cuff tear characterization. This review establishes guidelines for reporting shoulder-specific QUBIT aimed at developing a standardized imaging protocol. The objective was to enhance the diagnostic and prognostic capabilities of QUBIT in the clinical setting.
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Affiliation(s)
- Andrew J. Nasr
- Department of Applied Clinical Research, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Chris J. Pierson
- Department of Applied Clinical Research, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Yi-Ting Tzen
- Department of Applied Clinical Research, University of Texas Southwestern, Dallas, TX 75390, USA
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX 75390, USA
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Michael Khazzam
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Nitin B. Jain
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX 75390, USA
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Yen-Sheng Lin
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX 75390, USA
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern, Dallas, TX 75390, USA
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Kim DS, Han JY, Park YJ, Kwak JW, Lee BS. Comparative analysis of superior capsule reconstruction between long head of biceps tendon autograft and human dermis allograft. J Shoulder Elbow Surg 2023; 32:820-831. [PMID: 36174817 DOI: 10.1016/j.jse.2022.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/18/2022] [Accepted: 08/11/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although many superior capsule reconstruction (SCR) techniques are currently practiced in clinical settings, guidelines for choosing the appropriate graft material are lacking. Therefore, at most times, the surgeon's personal preference becomes the deciding factor. This study compared 2 fairly recent SCR techniques-SCR with biceps tendon (BT) autograft and SCR with human dermis (HD) allograft-by evaluating clinical and radiologic outcomes to aid the surgeon's decision in choosing the appropriate graft. METHODS Thirty-one patients underwent SCR using BT autograft (SCR BT), and 22 underwent SCR using HD allograft (SCR HD). SCR BT was selected for patients with a partial BT tear <20%, no severe inflammation signs, and favorable anchor conditions. SCR HD was performed in patients with a BT tear >20%, a superior labrum anterior-posterior (SLAP) lesion, severe inflammation, or subluxation. Range of motion (ROM), strength and shoulder function scoring, plain radiography, and magnetic resonance imaging were evaluated before and after surgery at regular intervals. RESULTS In the SCR BT group, forward flexion ROM increased from 122° ± 43° to 149° ± 18° at 2 years postoperatively, whereas in the SCR HD group, forward flexion ROM improved from 129° ± 28° to 149° ± 18°. In the SCR BT group, internal rotation (IR) ROM increased from 5 ± 3 to 6 ± 2 at 2 years postoperatively, whereas in the SCR HD group, IR ROM improved from 5 ± 3 to 6 ± 1. Although ROM, strength, visual analog scale score, American Shoulder and Elbow Surgeons score, and Constant score all improved 2 years after surgery, no statistically significant differences were found. Six months after surgery, graft thickness was 3.58 ± 0.384 mm in the SCR BT group and 2.49 ± 0.326 mm in the SCR HD group (P < .001). At 2 years postoperatively, graft thickness was 3.54 ± 0.399 mm in the SCR BT group and 2.49 ± 0.306 mm in the SCR HD group (P < .001). The SCR HD group showed a negative correlation of -0.475 between graft thickness and IR ROM (P = .026). In the SCR BT group, a negative correlation of -0.466 was found between graft thickness and IR ROM (P = .008). A positive correlation of 0.363 was found between IR ROM and the acromiohumeral distance when the results were compared before and 2 years after surgery (P = .045). CONCLUSION Both SCR using BT autograft and SCR using HD allograft tissue showed favorable results, and no significant difference was noted between the 2 techniques. Given that the 2 techniques show equally favorable results, the surgeon's personal preference in choosing the SCR technique appears to be acceptable. Understanding the costs and patient's characteristics may aid the surgeon in deciding on the graft material.
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Affiliation(s)
- Doo Sup Kim
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Jin Young Han
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea.
| | - Yeon Jae Park
- Department of Medical Statistics, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Ji Woong Kwak
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Bum Seok Lee
- Department of Orthopedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, Wonju, Republic of Korea
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Eliasberg CD, Carballo CB, Piacentini A, Caughey S, Havasy J, Khan M, Liu Y, Ivasyk I, Rodeo SA. Effect of CCR2 Knockout on Tendon Biomechanical Properties in a Mouse Model of Delayed Rotator Cuff Repair. J Bone Joint Surg Am 2023; 105:779-788. [PMID: 36947666 DOI: 10.2106/jbjs.22.01160] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND The high incidence of incomplete or failed healing after rotator cuff repair (RCR) has led to an increased focus on the biologic factors that affect tendon-to-bone healing. Inflammation plays a critical role in the initial tendon-healing response. C-C chemokine receptor type 2 (CCR2) is a chemokine receptor linked to the recruitment of monocytes in early inflammatory stages and is associated with an increase in pro-inflammatory macrophages. The purpose of this study was to evaluate the role of CCR2 in tendon healing following RCR in C57BL/6J wildtype (WT) and CCR2-/- knockout (CCR2KO) mice in a delayed RCR model. METHODS Fifty-two 12-week-old, male mice were allocated to 2 groups (WT and CCR2KO). All mice underwent unilateral supraspinatus tendon (SST) detachment at the initial surgical procedure, followed by a delayed repair 2 weeks later. The primary outcome measure was biomechanical testing. Secondary measures included histology, gene expression analysis, flow cytometry, and gait analysis. RESULTS The mean load-to-failure was 1.64 ± 0.41 N in the WT group and 2.50 ± 0.42 N in the CCR2KO group (p = 0.030). The mean stiffness was 1.43 ± 0.66 N/mm in the WT group and 3.00 ± 0.95 N/mm in the CCR2KO group (p = 0.008). Transcriptional profiling demonstrated 7 differentially expressed genes (DEGs) when comparing the CCR2KO and WT groups (p < 0.05) and significant differences in Type-I and Type-II interferon pathway scores (p < 0.01). Flow cytometry demonstrated significant differences between groups for the percentage of macrophages present (8.1% for the WT group compared with 5.8% for the CCR2KO group; p = 0.035). Gait analysis demonstrated no significant differences between groups. CONCLUSIONS CCR2KO may potentially improve tendon biomechanical properties by decreasing macrophage infiltration and/or by suppressing inflammatory mediator pathways in the setting of delayed RCR. CLINICAL RELEVANCE CCR2 may be a promising target for novel therapeutics that aim to decrease failure rates following RCR.
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Affiliation(s)
- Claire D Eliasberg
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Camila B Carballo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Alexander Piacentini
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Sarah Caughey
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Janice Havasy
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Marjan Khan
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Yulei Liu
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine, Peking University, Beijing, People's Republic of China
| | - Iryna Ivasyk
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
| | - Scott A Rodeo
- Orthopaedic Soft Tissue Research Program, Hospital for Special Surgery, New York, NY
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Marshall BP, Levine WN, Thomopoulos S. The Role of the Subacromial Bursa in Rotator Cuff Healing: Friend or Foe? J Bone Joint Surg Am 2023; 105:417-425. [PMID: 36575165 PMCID: PMC10353884 DOI: 10.2106/jbjs.22.00680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Resorbable Bioinductive Collagen Implant Is Cost Effective in the Treatment of Rotator Cuff Tears. Arthrosc Sports Med Rehabil 2023; 5:e367-e374. [PMID: 37101868 PMCID: PMC10123441 DOI: 10.1016/j.asmr.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 01/04/2023] [Indexed: 02/13/2023] Open
Abstract
Purpose This study was conducted to investigate whether the use of resorbable bioinductive collagen implant (RBI) in addition to conventional rotator cuff repair (conventional RCR) is cost-effective when compared to conventional RCR alone, in the treatment of full-thickness rotator cuff tears (FT RCT). Methods We developed a decision analytic model to compare the expected incremental cost and clinical consequences for a cohort of patients with FT RCT. The probabilities for healing or failure to heal (retear) were estimated from the published literature. Implant and healthcare costs were estimated from a payor's perspective in 2021 U.S. prices. An additional analysis included indirect cost estimations (e.g., productivity losses). Sensitivity analyses explored the effect of tear size, as well as the impact of risk factors. Results The base case analysis demonstrated that resorbable bioinductive collagen implant + conventional rotator cuff repair results in incremental costs of $232,468 and an additional 18 healed RCTs per 100 treated patients over 1 year. The estimated incremental cost-effectiveness ratio (ICER) is $13,061/healed RCT compared to conventional RCR alone. When return to work was included in the model, RBI + conventional RCR was found to be cost saving. Cost-effectiveness improved with tear size with the largest benefit seen in massive tears compared to large tears, as well as patients at higher risk of retearing. Conclusions This economic analysis demonstrated that RBI + conventional RCR delivered improved healing rates at a marginal increase in costs when compared to conventional RCR alone and is, therefore, cost-effective in this patient population. Considering indirect costs, RBI + conventional RCR resulted in lower costs compared to conventional RCR alone and is, therefore, deemed to be cost saving. Level of Evidence Level IV, economic analysis.
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Bolam SM, Konar S, Gamble G, Paine SJ, Dalbeth N, Monk AP, Coleman B, Cornish J, Munro JT, Musson DS. Ethnicity, sex, and socioeconomic disparities in the treatment of traumatic rotator cuff injuries in Aotearoa/New Zealand. J Shoulder Elbow Surg 2023; 32:121-132. [PMID: 35926830 DOI: 10.1016/j.jse.2022.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/28/2022] [Accepted: 06/19/2022] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND Traumatic rotator cuff injuries can be a leading cause of prolonged shoulder pain and disability and contribute to significant morbidity and health care costs. Previous studies have shown evidence of sociodemographic disparities with these injuries. The purpose of this nationwide study was to better understand these disparities based on ethnicity, sex, and socioeconomic status, in order to inform future health care strategies. METHODS Accident Compensation Corporation (ACC) is a no-fault comprehensive compensation scheme encompassing all of Aotearoa/New Zealand (population in 2018, 4.7 million). Using the ACC database, traumatic rotator cuff injuries were identified between January 2010 and December 2018. Injuries were categorized by sex, ethnicity, age, and socioeconomic deprivation index of the claimant. RESULTS During the 9-year study period, there were 351,554 claims accepted for traumatic rotator cuff injury, which totaled more than NZ$960 million. The greatest proportion of costs was spent on vocational support (49.8%), then surgery (26.3%), rehabilitation (13.1%), radiology (8.1%), general practitioner (1.6%), and "Other" (1.1%). Asian, Māori (indigenous New Zealanders), and Pacific peoples were under-represented in the age-standardized proportion of total claims and had lower rates of surgery than Europeans. Māori had higher proportion of costs spent on vocational support and lower proportions spent on radiology, rehabilitation, and surgery than Europeans. Males had higher number and costs of claims and were more likely to have surgery than females. There were considerably fewer claims from areas of high socioeconomic deprivation. DISCUSSION AND CONCLUSION This large nationwide study demonstrates the important and growing economic burden of rotator cuff injuries. Indirect costs, such as vocational supports, are a major contributor to the cost, suggesting improving treatment and rehabilitation protocols would have the greatest economic impact. This study has also identified sociodemographic disparities that need to be addressed in order to achieve equity in health outcomes.
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Affiliation(s)
- Scott M Bolam
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand; Department of Orthopedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - Subhajit Konar
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand
| | - Greg Gamble
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand
| | - Sarah-Jane Paine
- Te Kupenga Hauora Maori, University of Auckland, Grafton, Auckland, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand
| | - A Paul Monk
- Department of Orthopedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand; Auckland Bioengineering Institute, University of Auckland, Grafton, Auckland, New Zealand
| | - Brendan Coleman
- Department of Orthopedic Surgery, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Jillian Cornish
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand
| | - Jacob T Munro
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand; Department of Orthopedic Surgery, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - David S Musson
- Department of Medicine, University of Auckland, Grafton, Auckland, New Zealand; Department of Nutrition and Dietetics, University of Auckland, Grafton, Auckland, New Zealand.
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22
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Zhao W, Yang J, Kang Y, Hu K, Jiao M, Zhao B, Jiang Y, Liu C, Ding F, Yuan B, Ma B, Zhang K, Mikos AG, Zhang X. Animal Models of Rotator Cuff Injury and Repair: A Systematic Review. TISSUE ENGINEERING. PART B, REVIEWS 2022; 28:1258-1273. [PMID: 35972750 DOI: 10.1089/ten.teb.2022.0034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There are a large number of animal studies on rotator cuff injury and repair, but a lack of detailed research and evaluation on the animal models. This systematic review aims to provide a framework for animal studies and repair patches for rotator cuff injury. Four hundred nine animal studies were included, of which the most common animal model of rotator cuff injury is rat (53.56%), the most common site of rotator cuff injury is the supraspinatus tendon (62.10%), and the most common injury type (degree) is acute tear (full thickness) (48.41%). The most common research purpose is to evaluate the repair effect of the patch (24.94%), followed by the observation of pathophysiological changes after rotator cuff injury (20.87%). Among the five types of repair patch materials including nondegradable and degradable synthetic materials, autologous and allogeneic tissues, and naturally derived biomaterial, the last one is the mostly used (52.74%). For different animal models, the rodent models (rat and mouse) are the most commonly used and probably the most suitable species for preliminary studies of rotator cuff injury; the rabbit, canine, sheep, and goat models are more suitable for biomechanical performance testing, rehabilitation training, and validation of surgical methods; and the nonhuman primate models (monkey and baboon) are the closest to human, but it is more difficult to carry out the animal studies on them because of ethical issues, high feeding cost, and management difficulties.
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Affiliation(s)
- Wanlu Zhao
- College of Biomedical Engineering and Sichuan University, Chengdu, People's Republic of China.,National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, People's Republic of China
| | - Jinwei Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China.,Reproductive Medicine Center, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, People's Republic of China
| | - Yuhao Kang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
| | - Kaiyan Hu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Mingyue Jiao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Bing Zhao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Yanbiao Jiang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China.,The First Hospital of Lanzhou University, Lanzhou, People's Republic of China
| | - Chen Liu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Fengxing Ding
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Bo Yuan
- College of Biomedical Engineering and Sichuan University, Chengdu, People's Republic of China.,National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, People's Republic of China
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, People's Republic of China
| | - Kai Zhang
- College of Biomedical Engineering and Sichuan University, Chengdu, People's Republic of China.,National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, People's Republic of China.,Institute of Regulatory Science for Medical Devices, Sichuan University, Chengdu, People's Republic of China
| | - Antonios G Mikos
- Department of Bioengineering, Chemical and Biomolecular Engineering, Rice University, Houston, Texas, USA
| | - Xingdong Zhang
- College of Biomedical Engineering and Sichuan University, Chengdu, People's Republic of China.,National Engineering Research Center for Biomaterials, Sichuan University, Chengdu, People's Republic of China.,Institute of Regulatory Science for Medical Devices, Sichuan University, Chengdu, People's Republic of China
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23
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Fahy K, Galvin R, Lewis J, Mc Creesh K. Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis. Musculoskelet Sci Pract 2022; 61:102597. [PMID: 35724568 DOI: 10.1016/j.msksp.2022.102597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/05/2022] [Accepted: 06/01/2022] [Indexed: 01/26/2023]
Abstract
QUESTIONS To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs). DESIGN Systematic review with meta-analysis of randomised controlled trials (RCTs). PARTICIPANTS Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons. INTERVENTION Exercise as an intervention for L-MRCTTs. OUTCOME MEASURES Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I2 = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I2 = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes. CONCLUSION A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.
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Affiliation(s)
- Kathryn Fahy
- School of Allied Health, University of Limerick, Limerick, Ireland; Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.
| | - Rose Galvin
- School of Allied Health, University of Limerick, Limerick, Ireland; Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland
| | - Jeremy Lewis
- FCSP, Therapy Department, Central London Community Healthcare National Health Service Trust, London, United Kingdom; Department of Physical Therapy & Rehabilitation Science, College of Health Sciences, Qatar University, Doha, Qatar.
| | - Karen Mc Creesh
- School of Allied Health, University of Limerick, Limerick, Ireland.
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24
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Yoon JP, Kim DH, Min SG, Kim HM, Choi JH, Lee HJ, Park KH, Kim SS, Chung SW, Yoon SH. Effects of a graphene oxide-alginate sheet scaffold on rotator cuff tendon healing in a rat model. J Orthop Surg (Hong Kong) 2022; 30:10225536221125950. [PMID: 36121787 DOI: 10.1177/10225536221125950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Natural polymer scaffolds used to promote rotator cuff healing have limitations in terms of their mechanical and biochemical properties. This animal study aimed to investigate the effects of combined graphene oxide (GO) and alginate scaffold and the toxicity of GO on rotator cuff healing in a rat model. METHODS First, the mechanical properties of a GO/alginate scaffold and a pure alginate scaffold were compared. The in vitro cytotoxicity of and proliferation of human tenocytes with the GO/alginate scaffold were evaluated by CCK-8 assay. For the in vivo experiment, 20 male rats were randomly divided into two groups (n = 10 each), and supraspinatus repair was performed: group 1 underwent supraspinatus repair alone, and group 2 underwent supraspinatus repair with the GO/alginate scaffold. Biomechanical and histological analyses were performed to evaluate the quality of tendon-to-bone healing 8 weeks after rotator cuff repair. RESULTS The GO/alginate scaffold exhibited an increased maximum load (p = .001) and tensile strength (p = .001). In the cytotoxicity test, the cell survival rate with the GO/alginate scaffold was 102.08%. The proliferation rate of human tenocytes was no significant difference between the GO/alginate and alginate groups for 1, 3, 5, and 7 days. Biomechanically, group 2 exhibited a significantly greater ultimate failure load (p < .001), ultimate stress (p < .001), and stiffness (p < .001) than group 1. The histological analysis revealed that the tendon-to-bone interface in group 2 showed more collagen fibers bridging, tendon-to-bone integration, longitudinally oriented collagen fibers, and fibrocartilage formation than in group 1. CONCLUSION A small amount of GO added to alginate improved the mechanical properties of the scaffold without evidence of cytotoxicity. At 8 weeks after rotator cuff repair, the GO/alginate scaffold improved tendon-to-bone healing without causing any signs of toxicity in a rat model.
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Affiliation(s)
- Jong Pil Yoon
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Dong Hyun Kim
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Seung Gi Min
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Hun-Min Kim
- 65672Korea Dyeing & Finishing Technology Institute, Daegu, Korea
| | - Jin-Hyun Choi
- Department of Bio-Fibers and Materials Science, 34986Kyungpook National University, Daegu, Korea
| | - Hyun Joo Lee
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Kyeong Hyeon Park
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Seong Soo Kim
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
| | - Seok Won Chung
- Department of Orthopaedic Surgery, School of Medicine, 34986Konkuk University, Seoul, Korea
| | - Sung Hyuk Yoon
- Department of Orthopaedic Surgery, School of Medicine, 34986Kyungpook National University, Daegu, Korea
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25
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Kim WJ, Kim GH. A bioprinted complex tissue model for myotendinous junction with biochemical and biophysical cues. Bioeng Transl Med 2022; 7:e10321. [PMID: 36176596 PMCID: PMC9472009 DOI: 10.1002/btm2.10321] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/07/2022] [Accepted: 03/11/2022] [Indexed: 11/07/2022] Open
Abstract
In the musculoskeletal system, the myotendinous junction (MTJ) is optimally designed from the aspect of force transmission generated from a muscle through a tendon onto the bone to induce movement. Although the MTJ is a key complex tissue in force transmission, the realistic fabrication, and formation of complex tissues can be limited. To obtain the MTJ construct, we prepared two bioinks, muscle- and tendon-derived decellularized extracellular matrix (dECM), which can induce myogenic and tenogenic differentiation of human adipose-derived stem cells (hASCs). By using a modified bioprinting process supplemented with a nozzle consisting of a single-core channel and double-sheath channels, we can achieve three different types of MTJ units, composed of muscle, tendon, and interface zones. Our results indicated that the bioprinted dECM-based constructs induced hASCs to myogenic and tenogenic differentiation. In addition, a significantly higher MTJ-associated gene expression was detected at the MTJ interface with a cell-mixing zone than in the other interface models. Based on the results, the bioprinted MTJ model can be a potential platform for understanding the interaction between muscle and tendon cells, and even the bioprinting method can be extensively applied to obtain complex tissues.
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Affiliation(s)
- Won Jin Kim
- Department of Biomechatronic EngineeringCollege of Biotechnology and Bioengineering, Sungkyunkwan University (SKKU)SuwonRepublic of Korea
| | - Geun Hyung Kim
- Department of Biomechatronic EngineeringCollege of Biotechnology and Bioengineering, Sungkyunkwan University (SKKU)SuwonRepublic of Korea
- Biomedical Institute for Convergence at SKKU (BICS), Sungkyunkwan UniversitySuwonRepublic of Korea
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26
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Nguyen PK, Jana A, Huang C, Grafton A, Holt I, Giacomelli M, Kuo CK. Tendon mechanical properties are enhanced via recombinant lysyl oxidase treatment. Front Bioeng Biotechnol 2022; 10:945639. [PMID: 35992359 PMCID: PMC9389157 DOI: 10.3389/fbioe.2022.945639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Tendon mechanical properties are significantly compromised in adult tendon injuries, tendon-related birth defects, and connective tissue disorders. Unfortunately, there currently is no effective treatment to restore native tendon mechanical properties after postnatal tendon injury or abnormal fetal development. Approaches to promote crosslinking of extracellular matrix components in tendon have been proposed to enhance insufficient mechanical properties of fibrotic tendon after healing. However, these crosslinking agents, which are not naturally present in the body, are associated with toxicity and significant reductions in metabolic activity at concentrations that enhance tendon mechanical properties. In contrast, we propose that an effective method to restore tendon mechanical properties would be to promote lysyl oxidase (LOX)-mediated collagen crosslinking in tendon during adult tissue healing or fetal tissue development. LOX is naturally occurring in the body, and we previously demonstrated LOX-mediated collagen crosslinking to be a critical regulator of tendon mechanical properties during new tissue formation. In this study, we examined the effects of recombinant LOX treatment on tendon at different stages of development. We found that recombinant LOX treatment significantly enhanced tensile and nanoscale tendon mechanical properties without affecting cell viability or collagen content, density, and maturity. Interestingly, both tendon elastic modulus and LOX-mediated collagen crosslink density plateaued at higher recombinant LOX concentrations, which may have been due to limited availability of adjacent lysine residues that are near enough to be crosslinked together. The plateau in crosslink density at higher concentrations of recombinant LOX treatments may have implications for preventing over-stiffening of tendon, though this requires further investigation. These findings demonstrate the exciting potential for a LOX-based therapeutic to enhance tendon mechanical properties via a naturally occurring crosslinking mechanism, which could have tremendous implications for an estimated 32 million acute and chronic tendon and ligament injuries each year in the U.S.
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Affiliation(s)
- Phong K. Nguyen
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States
| | - Aniket Jana
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, United States
| | - Chi Huang
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
| | - Alison Grafton
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, United States
| | - Iverson Holt
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, United States
| | - Michael Giacomelli
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
| | - Catherine K. Kuo
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, United States
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, United States
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, United States
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, NY, United States
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
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27
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Engler ID. Editorial Commentary: Saving Cost in Orthopaedics While Preserving Patient Experience and Outcomes: We Can Have It All. Arthroscopy 2022; 38:2378-2380. [PMID: 35940737 DOI: 10.1016/j.arthro.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
Healthcare costs in the United States are the highest in the world and continue to increase unsustainably. As a result, cost-cutting measures are paramount. Bundled payments are a primary method to decrease healthcare use, and they are increasingly prominent in orthopaedic surgical care. Bundled payments require an accurate assessment of the cost of a procedure, which may be determined more reliably and feasibly than previously with time-driven activity-based costing. Time-driven activity-based costing identifies the cost of various stages of care, which allows cost-containment strategies to target the most expensive stages. Amidst the warranted focus on cost reduction, we must maintain a strong focus on the patient experience and patient outcomes. For example, reducing surgeon and staff time with the patient could negatively impact patient care, yet increasing efficiency in the operating room and perioperative setting could decrease the relative cost of staff without harming the patient experience. Other realms, such as implant and administrative costs, are important focuses that are less likely to directly hamper patient care. Controlling cost in the U.S. healthcare system will require a wide-reaching approach with contributions from all parties. As we work toward a more financially sustainable system, we must be sure to preserve excellent patient experience and outcomes.
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28
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Quigley R, Verma N, Evuarherhe A, Cole BJ. Rotator Cuff Repair with Graft Augmentation Improves Function, Decreases Revisions, and Is Cost-Effective. Arthroscopy 2022; 38:2166-2174. [PMID: 35066111 DOI: 10.1016/j.arthro.2022.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study is to evaluate the cost effectiveness of the use of extracellular matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision tree analysis. METHODS A decision tree model was created utilizing the existing literature for retear rates with and without dermal graft augmentation. Costs for rotator cuff repair (hospital and surgeon fees) were based on published studies and the cost for graft augmentation was based on institutional data. Utility measures were based upon EQ-5D (European Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted life years (QALY) over a 10-year postoperative period with and without graft augmentation. Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER), or the incremental cost for per QALY with graft augmentation. Cost effectiveness is based on previous literature whereby an intervention is considered cost effective if the ICER is less than $50,000/QALY. RESULTS On the basis of our decision tree analysis, total cost for rotator cuff tear without augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation. With graft augmentation there was an improvement in 2.29 QALY, while there was an improvement of 2.05 without graft augmentation. The ICER of graft augmentation is $14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity analysis showed the maximum cost of the ECM augment to be cost effective is $11,921. CONCLUSION Graft augmentation does come with a significant upfront cost; however, on the basis of our decision-tree analysis, it may represent a cost-effective procedure. There is evidence to potentially consider more routine use in rotator cuff repairs, while being cost effective. LEVEL OF EVIDENCE Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model) with inputs derived from Level IV studies.
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Affiliation(s)
- Ryan Quigley
- Kaiser Permanente, Sacramento, California, U.S.A
| | - Nikhil Verma
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Aghogho Evuarherhe
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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29
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Wallenberg RB, Belzer ML, Ramsey DC, Opel DM, Berkson MD, Gundle KR, Nagy ML, Boucher RJ, McCarron JA. MRI-based 3-dimensional volumetric assessment of fatty infiltration and muscle atrophy in rotator cuff tears. J Shoulder Elbow Surg 2022; 31:1272-1281. [PMID: 35101606 DOI: 10.1016/j.jse.2021.12.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/17/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Goutallier and Warner Classification systems are useful in determining rotator cuff reparability. Data are limited on how accurately the scapular-Y view used in both systems reflects the 3-dimensional (3-D) changes in fatty infiltration (FI) and muscle atrophy (MA). Tendon retraction in the setting of a cuff tear may also influence the perception of these changes. This study's objectives were to (1) measure the 3-D volume of the supraspinatus muscle in intact rotator cuffs, and with varying magnitudes of retraction; (2) measure the 3-D volume of FI in the supraspinatus muscle in these conditions; and (3) determine the influence of tendon retraction on measured FI and MA using the Goutallier and Warner Classification Systems. METHODS Between August 2015 and February 2016, all shoulder magnetic resonance images (MRIs) at the Portland VA Medical Center were standardized to include the medial scapular border. MRIs and charts were reviewed for inclusion/exclusion criteria. Included MRIs were categorized into 4 groups based on rotator cuff retraction. Supraspinatus muscle and fossa were traced to create 3-D volumes. FI and MA were measured within the supraspinatus. The supraspinatus muscle was graded among 6 physicians using the Goutallier and Warner classification systems. These grades were compared to 3-D measured FI and MA. The influence of tendon retraction on the measured grades were also evaluated. RESULTS One hundred nine patients met inclusion/exclusion criteria. Ten MRIs for each group (N = 40) were included for image analysis. Supraspinatus volume tracings were highly reproducible and consistent between tracers. Supraspinatus muscle volumes decreased while global FI and MA increased with greater degrees of tendon retraction. In muscles with less than 10% global fat, fat concentrated in the lateral third of the muscle. In muscle with more than 10% global fat content, it distributed more diffusely throughout the muscle from medial to lateral. In comparing the scapular-Y to a medial cut, there was no consistent trend in FI whereas MA was more accurate at the medial cut. CONCLUSION Parasagittal imaging location did not significantly influence the Goutallier score; however, assessment of MA using the Warner score leads readers to perceive less MA medially regardless of the magnitude of tendon retraction. The pattern of FI within the supraspinatus muscle changes from a laterally based location around the muscle-tendon junction to a more diffuse, global infiltration pattern when the whole muscle fat content exceeds 10%.
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Affiliation(s)
- Ryan B Wallenberg
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA.
| | - Mckenna L Belzer
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Dayton M Opel
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Mark D Berkson
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA
| | - Kenneth R Gundle
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA; Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Melba L Nagy
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA
| | - Ronald J Boucher
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA
| | - Jesse A McCarron
- Operative Care Division, Portland VA Medical Center, Portland, OR, USA
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30
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Li Z, Hu G, Zhu Y, Xu F, Ye J, Guan J, Guan H. Factors Associated with Shoulder Range of Motion After Arthroscopic Rotator Cuff Repair: A Hospital‐Based Prospective Study. Orthop Surg 2022; 14:1309-1316. [PMID: 35603551 PMCID: PMC9251286 DOI: 10.1111/os.13249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the factors associated with outcomes of arthroscopic surgical repair of rotator cuff tears (RCTs). Method This prospective study recruited patients, at least 18 years old, who underwent arthroscopic rotator cuff repair for full‐thickness RCTs at the First People's Hospital of Hangzhou Xiaoshan between July 2019 and October 2020. Patient demographics, lifestyle habits, and medical histories were collected preoperatively; RCT sizes and affected tendons were determined intraoperatively. Outcomes were assessed by shoulder range of motion (ROM) determinations 1.5 and 3 months postoperatively. The factors associated with ROM were determined using a binary logistic regression analysis, and the results were expressed as adjusted relative risks (RRs) and 95% confidence intervals (CIs). Results A total of 132 patients with RCTs underwent arthroscopic surgery. Five were lost to follow‐up, leaving 127 patients (mean age, 59 years; 58.3% women) who were included in the study analysis. The majority of the patients (54.5%) had RCTs that were classified as large or massive, and approximately 20% had tears involving multiple tendons; 80.3% of the patients had tears involving only a single tendon. Moreover, 29.9% of the patients had hypertension and 11.0% had diabetes. Among the patients, 23.0% were smokers and 34.6% drank alcohol. According to the multivariate analysis, none of the assessed factors were associated with shoulder ROM at the 1.5‐month follow‐up. At the 3‐month follow‐up, RCTs involving a single tendon demonstrated 3‐fold better abduction (RR = 4.00; 95% CI, 1.30–12.33; P = 0.016) and 3.15‐fold better internal rotation (RR = 3.15; 95% CI, 1.19–8.36; P = 0.021) than did RCTs involving multiple tendons. Patients who did not drink alcohol demonstrated 6.08‐fold better anteflexion (RR = 7.08; 95% CI, 2.11–23.73; P = 0.002) and nearly 4‐fold better abduction (RR = 4.97; 95% CI, 1.62–15.23; P = 0.005) than patients who drank alcohol. Conclusion To improve outcomes, the results indicate that more targeted measures should be directed toward patients with multiple‐tendon RCTs and that preoperative alcohol abstinence education is needed for patients with RCTs.
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Affiliation(s)
- Zhennan Li
- The Second Clinical Medicine College Zhejiang Chinese Medical University Hangzhou China
| | - Gangfeng Hu
- Department of Orthopaedics The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Yuan Zhu
- Department of Orthopaedics The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Fangqi Xu
- Department of Orthopaedics The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Jiakuan Ye
- Department of Orthopaedics The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Jie Guan
- Department of Orthopaedics The First People's Hospital of Xiaoshan District, Hangzhou, Zhejiang, China
| | - Hong Guan
- The Second Clinical Medicine College Zhejiang Chinese Medical University Hangzhou China
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Cunningham G, Cocor C, Smith MM, Young AA, Cass B, Moor BK. Implication of bone morphology in degenerative rotator cuff lesions: A prospective comparative study between greater tuberosity angle and critical shoulder angle. Orthop Traumatol Surg Res 2022; 108:103046. [PMID: 34487909 DOI: 10.1016/j.otsr.2021.103046] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Degenerative rotator cuff tear is a frequent and multifactorial pathology. The role of bone morphology of the greater tuberosity and lateral acromion has been validated, and can be measured with two plain radiographic markers on true anteroposterior views: the greater tuberosity angle (GTA) and the critical shoulder angle (CSA). However, the interdependence of both markers remains unknown, as well as their relationship with the level of professional and sports activities involving the shoulder. The aim of this prospective comparative study was to describe the correlation between the GTA and CSA in patients with degenerative rotator cuff tears. HYPOTHESIS GTA and CSA are independent factors from one another and from demographic factors, such as age, dominance, sports, or professional activities. PATIENT AND METHODS All patients presenting to a shoulder specialized clinic were assigned to two groups. The first consisted of patients with a symptomatic degenerative rotator cuff tear visible on MRI and the control group consisted of patients with any other shoulder complaints and no history or visible imaging of any rotator cuff lesion. RESULTS There were 51 shoulders in 49 patients in the rotator cuff tear group (RCT) and 53 shoulders in 50 patients in the control group. Patient demographics were similar in both groups. Mean GTA was 72.1°±3.7 (71.0-73.1) in the RCT group and 64.0°±3.3 (63.1-64.9) in the control group (p<0.001). Mean CSA was 36.7°±3.7 (35.7-37.8) in the RCT group, and 32.1°±3.7 (31.1-33.1) in the control group (p<0.001). A summation of GTA and CSA values over 103° increased the odds of having a rotator cuff tear by 97-fold (p<0.001). There was no correlation between GTA and CSA, nor between GTA or CSA and age, sex, tear size, or dominance. Patients with different levels of professional and sports activities did not have significantly different GTA or CSA values. CONCLUSION GTA and CSA are independent radiologic markers that can reliably predict the presence of a degenerative rotator cuff tear. A sum of both values over 103° increases the odds of having a rotator cuff tear by 97-fold. These markers are not correlated with patient demographic or environmental factors, suggesting that the variability of the native acromion and greater tuberosity morphology may be individual risk factors for rotator cuff tear. LEVEL OF EVIDENCE II; diagnostic study.
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Affiliation(s)
- Gregory Cunningham
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland; Shoulder Center, Hirslanden Clinique la Colline, Geneva, Switzerland.
| | - Cristina Cocor
- Division of Orthopaedics and Trauma Surgery, Lausanne University Hospital, Geneva, Switzerland
| | | | - Allan A Young
- Sydney Shoulder Research Institute, Sydney, Australia
| | - Benjamin Cass
- Sydney Shoulder Research Institute, Sydney, Australia
| | - Beat K Moor
- Division of Orthopaedics and Trauma Surgery, Hôpital du Valais, Martigny, Switzerland
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32
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Grusky AZ, Giri A, O’Hanlon D, Jain NB. The Relationship of Aging and Smoking With Rotator Cuff Disease: A Systematic Review and Meta-analysis. Am J Phys Med Rehabil 2022; 101:331-340. [PMID: 34121068 PMCID: PMC8665931 DOI: 10.1097/phm.0000000000001820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite rotator cuff disease being one of the most common causes of shoulder pain, its pathogenesis and biology are poorly understood. In this study, we synthesized evidence from studies reporting associations for aging and smoking status in relation to rotator cuff disease. DESIGN A systematic review was performed using multiple databases (PubMed, Embase, Cochrane, CINAHL, and Science Direct). Articles that met our eligibility criteria and presented data on the association between aging and/or smoking status and rotator cuff disease were included. We performed meta-analyses and reported cumulative effects using odds ratios and corresponding 95% confidence intervals. RESULTS Of the 212 articles eligible for full-text review, seven studies reported on the relationship between aging and rotator cuff disease, and 10 studies reported on the relationship between smoking and rotator cuff disease. Aging was consistently associated with increased odds of having rotator cuff disease when assessed continuously (per 10-yr increase: odds ratio = 1.20, 95% confidence interval = 1.18-1.21) or categorically (ages <40 yrs vs: [a] 40-44 yrs [odds ratio = 2.71, 95% confidence interval = 1.78-4.13], [b] 45-49 yrs [odds ratio = 4.33, 95% confidence interval = 2.88-6.55], and [c] ≥50 yrs [odds ratio = 6.97, 95% confidence interval = 4.85-10.01]). Assessing studies that reported smoking status as current smokers versus nonsmokers, current smokers were more likely to have rotator cuff disease (odds ratio = 1.94, 95% confidence interval = 1.52-2.48). However, a statistically significant association was not found when never smokers were compared with former smokers (odds ratio = 1.08, 95% confidence interval = 0.97-1.20) and to current smokers (odds ratio = 0.97, 95% confidence interval = 0.87-1.07). CONCLUSIONS In this systematic review and meta-analysis, increasing age was a strong risk factor for rotator cuff disease. The finding that current smokers are more likely to have rotator cuff disease as compared with nonsmokers implies that cessation of smoking can potentially lead to mitigation of this risk factor.
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Affiliation(s)
| | - Ayush Giri
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Nitin B. Jain
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
- Departments of Physical Medicine and Rehabilitation, Orthopaedics, and Population & Data Sciences, University of Texas Southwestern
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Yang J, Kang Y, Zhao W, Jiang J, Jiang Y, Zhao B, Jiao M, Yuan B, Zhao J, Ma B. Evaluation of patches for rotator cuff repair: A systematic review and meta-analysis based on animal studies. Bioact Mater 2022; 10:474-491. [PMID: 34901561 PMCID: PMC8633530 DOI: 10.1016/j.bioactmat.2021.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Based on the published animal studies, we systematically evaluated the outcomes of various materials for rotator cuff repair in animal models and the potentials of their clinical translation. 74 animal studies were finally included, of which naturally derived biomaterials were applied the most widely (50.0%), rats were the most commonly used animal model (47.0%), and autologous tissue demonstrated the best outcomes in all animal models. The biomechanical properties of naturally derived biomaterials (maximum failure load: WMD 18.68 [95%CI 7.71-29.66]; P = 0.001, and stiffness: WMD 1.30 [95%CI 0.01-2.60]; P = 0.048) was statistically significant in the rabbit model. The rabbit model showed better outcomes even though the injury was severer compared with the rat model.
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Affiliation(s)
- Jinwei Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
- Reproductive Medicine Center, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, 730050, China
| | - Yuhao Kang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Wanlu Zhao
- College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
- National Engineering Research Center for Biomaterials, Chengdu, 610064, China
| | - Jia Jiang
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Yanbiao Jiang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Bing Zhao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Mingyue Jiao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
| | - Bo Yuan
- College of Biomedical Engineering, Sichuan University, Chengdu, 610064, China
- National Engineering Research Center for Biomaterials, Chengdu, 610064, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, 730000, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, 730000, China
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34
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Washington KS, Shemshaki NS, Laurencin CT. The Role of Nanomaterials and Biological Agents on Rotator Cuff Regeneration. REGENERATIVE ENGINEERING AND TRANSLATIONAL MEDICINE 2022; 7:440-449. [PMID: 35005215 DOI: 10.1007/s40883-020-00171-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The rotator cuff is a musculotendon unit responsible for movement in the shoulder. Rotator cuff tears represent a significant number of musculoskeletal injuries in the adult population. In addition, there is a high incidence of retear rates due to various complications within the complex anatomical structure and the lack of proper healing. Current clinical strategies for rotator cuff augmentation include surgical intervention with autograft tissue grafts and beneficial impacts have been shown, but challenges still exist because of limited supply. For decades, nanomaterials have been engineered for the repair of various tissue and organ systems. This review article provides a thorough summary of the role nanomaterials, stem cells and biological agents have played in rotator cuff repair to date and offers input on next generation approaches for regenerating this tissue.
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Affiliation(s)
- Kenyatta S Washington
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health, Farmington, CT 06030, USA
| | - Nikoo Saveh Shemshaki
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health, Farmington, CT 06030, USA.,Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA.,Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA.,Department of Orthopedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Cato T Laurencin
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health, Farmington, CT 06030, USA.,Raymond and Beverly Sackler Center for Biomedical, Biological, Physical and Engineering Sciences, University of Connecticut Health Center, Farmington, CT 06030, USA.,Department of Biomedical Engineering, University of Connecticut, Storrs, CT 06269, USA.,Department of Orthopedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA.,Department of Materials Science and Engineering, University of Connecticut, Storrs, CT 06269, USA.,Department of Chemical & Biomolecular Engineering, University of Connecticut, Storrs, CT 06269, USA.,Department of Craniofacial Sciences, School of Dental Medicine, University of Connecticut Health, Farmington, CT 06030, USA
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Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care. J Shoulder Elbow Surg 2022; 31:72-80. [PMID: 34390841 DOI: 10.1016/j.jse.2021.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/25/2021] [Accepted: 07/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care. METHODS Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed. RESULTS The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r2 = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01). CONCLUSION RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.
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Ma J, Sahoo S, Imrey PB, Jin Y, Baker AR, Entezari V, Ho JC, Iannotti JP, Ricchetti ET, Polster JM, Winalski CS, Derwin KA. Inter-rater agreement of rotator cuff tendon and muscle magnetic resonance imaging parameters evaluated preoperatively and during the first postoperative year following rotator cuff repair. J Shoulder Elbow Surg 2021; 30:e741-e752. [PMID: 33930556 PMCID: PMC8551316 DOI: 10.1016/j.jse.2021.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/30/2021] [Accepted: 04/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is standard of care for rotator cuff evaluation, with clinical interpretation usually limited to qualitative judgments. The reliability of MRI-based measurements and scoring systems has been evaluated only preoperatively or ≥6 months following rotator cuff repair, when repairs are in the later stages of healing. This study describes the MRI assessments and inter-rater agreement of various rotator cuff tendon and muscle parameters evaluated preoperatively and 4 times during the first postoperative year. METHODS Two musculoskeletal radiologists independently assessed MRI scans of 42 patients preoperatively and 3, 12, 26, and 52 weeks after rotator cuff repair. Using standardized reading rules, readers assessed tendon integrity (5-point Sugaya classification), tear dimensions, muscle fat (5-point Goutallier classification) and atrophy (4-point Warner classification), muscle cross-sectional areas, and myotendinous junction distance. Raw exact agreement proportions, κ statistics, and correlation coefficients were used to quantify inter-rater agreement. RESULTS Readers showed moderate to substantial above-chance agreement in scoring rotator cuff tendon integrity and supraspinatus muscle atrophy and good to excellent agreement on tear dimensions and muscle cross-sectional areas but only fair to moderate agreement for fatty infiltration and myotendinous junction distance. Only fatty infiltration grades evidenced observer bias. Inter-rater agreement did not appear time dependent. CONCLUSION By use of defined reading rules in a research setting, MRI evaluations of rotator cuff tendon integrity, tear dimensions, muscle atrophy, and cross-sectional areas have reasonable reliability at all time points in the first postoperative year. However, the presence of clinically significant disagreements, even in such favorable circumstances, indicates the need for improved imaging tools for precise rotator cuff evaluation.
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Affiliation(s)
- Jinjin Ma
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Sambit Sahoo
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Yuxuan Jin
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew R. Baker
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
| | - Vahid Entezari
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jason C. Ho
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Eric T. Ricchetti
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua M. Polster
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Carl S. Winalski
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Kathleen A. Derwin
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Condron NB, Kester BS, Tokish JM, Zumstein MA, Gobezie R, Scheibel M, Cole BJ. Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review. Arthroscopy 2021; 37:3200-3218. [PMID: 34293441 DOI: 10.1016/j.arthro.2021.06.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/16/2021] [Indexed: 02/02/2023]
Abstract
Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.
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Affiliation(s)
| | | | | | - Matthias A Zumstein
- Orthopaedics Sonnenhof, Bern, and Department of Orthopaedics and Traumatology, University of Bern, Inselspital, Bern, Switzerland
| | | | - Markus Scheibel
- Department for Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland; Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin, Berlin, Germany
| | - Brian J Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A..
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Gagnier J, Bedi A, Carpenter J, Robbins C, Miller B. A 5-Year Follow-up of Patients Treated for Full-Thickness Rotator Cuff Tears: A Prospective Cohort Study. Orthop J Sports Med 2021; 9:23259671211021589. [PMID: 34514008 PMCID: PMC8427933 DOI: 10.1177/23259671211021589] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/25/2021] [Indexed: 12/25/2022] Open
Abstract
Background: The evidence in support of operative versus nonoperative management of rotator cuff tears (RCTs) is limited, based primarily on observational studies of lower scientific merit. Purpose: To (1) compare the efficacy of operative versus nonoperative management of full-thickness RCTs across time and (2) detect variables that predict success within each group. Study Design: Cohort study; Level of evidence, 2. Methods: We included patients with symptomatic full-thickness RCTs who were enrolled in an institutional shoulder registry. Patient enrollment began in 2009 and continued until early 2018. The following outcome measures were collected at baseline, then 6 months, 1 year, and annually up to 5 years postoperatively: Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score, Veterans RAND 12-Item Health Survey (VR-12) mental and physical component subscales (MCS and PCS, respectively), 100-point Single Assessment Numeric Evaluation (SANE) rating, and 100-point visual analog scale (VAS) for pain and for patient satisfaction. We performed regression models for all outcome variables across all 5 years of follow-up and included the following predictor variables: treatment type (operative vs nonoperative), sex, age, symptom duration, smoking status, diabetes status, injury side, and obesity status. Results: A total of 595 patients were included. Longitudinal mixed-effects regression revealed that patients who received operative treatment did better across time on all outcomes. Women (n = 242; 40.7%) did not fare as well as did men on the ASES, WORC, or VR-12 PCS. Older patients tended to improve less on the VR-12 PCS and more on the VR12-MCS. Patients with longer symptom duration at baseline had better scores across time on the ASES, WORC, VAS for pain, and SANE. Current or recent smokers and patients with diabetes tended to have lower scores on all measures across time. For changes in scores from baseline, patients in the operative group improved to a larger degree out to 3 years compared with those in the nonoperative group. Conclusion: Patients with RCTs tended to improve regardless of whether they received operative or nonoperative treatment, but patients who underwent operative treatment improved faster. There appear to be several predictors of improved and worsened outcomes for patients with RCTs undergoing operative or nonoperative treatment.
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Affiliation(s)
- Joel Gagnier
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA.,Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - James Carpenter
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Bruce Miller
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Parikh N, Martinez DJ, Winer I, Costa L, Dua D, Trueman P. Direct and indirect economic burden associated with rotator cuff tears and repairs in the US. Curr Med Res Opin 2021; 37:1199-1211. [PMID: 33879008 DOI: 10.1080/03007995.2021.1918074] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This retrospective study examined treatment characteristics and the economic burden associated with rotator cuff tears (RCT) and rotator cuff repairs (RCR). Additionally, this study aimed to explore the economic implications associated with delayed surgical intervention. METHODS Adult RCT patients meeting eligibility criteria were identified from 1/1/2013-6/30/2017 using the IBM Watson Health MarketScan Commercial database. Patients with incident RCR within 12 months post-index and 12 months continuous enrollment after the RCR date were also analyzed. Early surgery was defined as RCR within 6 months and 1 month from the partial-thickness tear and full-thickness tear diagnoses, respectively. Patient characteristics, all-cause direct costs (plan paid and patient out-of-pocket), RCT-related costs, pre-surgical costs, post-surgical costs, and healthcare resource utilization were reported by RCT type. Attributable indirect costs, absenteeism and short-term disability (STD), were also estimated. RESULTS 102,488 RCT patients were identified (partial-thickness tears: 46,856 [45.7%]; full-thickness tears: 55,632 [54.3%]). Fifty per cent RCT patients underwent RCR within 12-months of diagnosis. Full-thickness RCT patients had an average total baseline (one year pre-diagnosis) and post-index costs of $17,096 and $32,110, respectively. Similarly, partial thickness patients had baseline costs of $16,385 and post-index costs of $27,017. Mean all-cause annual post-surgery costs were $34,086 for patients with partial-thickness tears and $34,249 for patients with full-thickness tears, of which 40% and 38% of costs were RCT-related, respectively. Productivity losses due to absenteeism and STD in the 12-month post-surgery period averaged $5843 and $4493, respectively, for partial-thickness tear patients and $5770 and $4382, respectively, for full-thickness tear patients. Average additional spending per delayed surgical patient between diagnosis and surgery was $8524 and $3213 (both p <0.001) for partial- and full-thickness tear patients, respectively. CONCLUSIONS This exploratory analysis indicates considerable RCT and RCR economic burden to the healthcare system. High healthcare utilization and costs highlight the importance of efficiently managing patients with RCT diagnosis. Data also suggest that early surgical intervention may be economically beneficial if surgical intervention is anticipated post-RCT.
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Affiliation(s)
| | - Diane J Martinez
- Arlington County Department of Human Services, Arlington, VA, USA
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Zhang C, Wu J, Li X, Wang Z, Lu WW, Wong TM. Current Biological Strategies to Enhance Surgical Treatment for Rotator Cuff Repair. Front Bioeng Biotechnol 2021; 9:657584. [PMID: 34178957 PMCID: PMC8226184 DOI: 10.3389/fbioe.2021.657584] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023] Open
Abstract
Rotator cuff tear is one of the most common shoulder problems encountered by orthopedic surgeons. Due to the slow healing process and high retear rate, rotator cuff tear has distressed millions of people all around the world every year, especially for the elderly and active athletes. This disease significantly impairs patients' motor ability and reduces their quality of life. Besides conservative treatment, open and arthroscopic surgery contributes a lot to accelerate the healing process of rotator cuff tear. Currently, there are many emerging novel treatment methods to promote rotator cuff repair. A variety of biological stimulus has been utilized in clinical practice. Among them, platelet-rich plasma, growth factors, stem cells, and exosomes are the most popular biologics in laboratory research and clinical trials. This review will focus on the biologics of bioaugmentation methods for rotator cuff repair and tendon healing, including platelet-rich plasma, growth factors, exosomes and stem cells, etc. Relevant studies are summarized in this review and future research perspectives are introduced.
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Affiliation(s)
- Cheng Zhang
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jun Wu
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xiang Li
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zejin Wang
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Weijia William Lu
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Center for Human Tissues and Organs Degeneration, Shenzhen Institutes of Advanced Technology (CAS), Shenzhen, China
| | - Tak-Man Wong
- Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, Guangdong Engineering Technology Research Center for Orthopaedic Trauma Repair, Department of Orthopaedics and Traumatology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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Prinja A, Sabharwal S, Moshtael S, Dey P, Monga P. Measuring outcomes in rotator cuff disorders. J Clin Orthop Trauma 2021; 19:187-191. [PMID: 34141572 PMCID: PMC8178113 DOI: 10.1016/j.jcot.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022] Open
Abstract
Measuring the outcome of treatment for rotator cuff disorders has evolved over the last three decades. Objective surgeon-derived outcomes such as clinical examination findings and imaging of the rotator cuff have the limitation of marginalising the patients perception of their condition. Patient reported outcome measures (PROMs) have evolved and become popular in an attempt to demonstrate meaningful outcome data. There are a large number in use today and as a result, the heterogeneity of scores used across the literature can make comparison difficult. Patient reported outcome scores can be general health related quality of life scores, joint-specific and disease specific. Qualitative outcomes are also being used now, and these help us to better understand the context of quantitative research scores. In this article, we provide an overview of the outcome measures used in rotator cuff disorders.
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Affiliation(s)
- Aditya Prinja
- Upper Limb Unit, Wrightington Hospital, Wigan, UK,Corresponding author.
| | | | | | - Paola Dey
- Faculty of Health, Social Care & Medicine, Edge Hill University, Lancashire, UK
| | - Puneet Monga
- Upper Limb Unit, Wrightington Hospital, Wigan, UK
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Zhu C, Qiu J, Thomopoulos S, Xia Y. Augmenting Tendon-to-Bone Repair with Functionally Graded Scaffolds. Adv Healthc Mater 2021; 10:e2002269. [PMID: 33694312 PMCID: PMC8102396 DOI: 10.1002/adhm.202002269] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/24/2021] [Indexed: 12/14/2022]
Abstract
Tendon-to-bone repair often fails because the functionally graded attachment is not regenerated during the healing process. Biomimetic scaffolds that recapitulate the unique features of the native tendon-to-bone attachment hold great promise for enhancing the healing process. Among various types of scaffolds that are developed and evaluated for tendon-to-bone repair, those with gradations (in either a stratified or a continuous fashion) in composition, structure, mechanical properties, and cell phenotype have gained the most attention. In this progress report, the recent efforts in the rational design and fabrication of functionally graded scaffolds based upon electrospun nanofiber mats and inverse opal structures, as well as the evaluation of their applications in augmenting tendon-to-bone repair, are reviewed. This report concludes with perspectives on the necessary future steps for clinical translation of the scaffolds.
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Affiliation(s)
- Chunlei Zhu
- Key Laboratory of Functional Polymer Materials of Ministry of Education, State Key Laboratory of Medicinal Chemical Biology, Institute of Polymer Chemistry, College of Chemistry, Nankai University, Tianjin, 300071, China
| | - Jichuan Qiu
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, 30332, USA
| | - Stavros Thomopoulos
- Department of Orthopedic Surgery, Columbia University, New York, NY, 10032, USA
- Department of Biomedical Engineering, Columbia University, New York, NY, 10027, USA
| | - Younan Xia
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, 30332, USA
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, GA, 30332, USA
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Thangarajah T, Lo IK, Sabo MT. Rotator cuff repair techniques: Current concepts. J Clin Orthop Trauma 2021; 17:149-156. [PMID: 33854942 PMCID: PMC8022250 DOI: 10.1016/j.jcot.2021.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/04/2023] Open
Abstract
Arthroscopic rotator cuff repair is being performed by an ever-increasing number of surgeons. With an ageing population and growing patient expectations it is crucial that clinical outcomes are optimised. Anatomical reduction of the tendon back to its footprint with minimal tension contributes to this, but this can only be achieved if key biomechanical factors are taken into consideration. In this review of the technical aspects of a rotator cuff repair, we focus on: (1) patient positioning, (2) biomechanical principles, (3) optimal visualisation, and (4) repair techniques for both anterior and postero-superior tears.
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Affiliation(s)
- Tanujan Thangarajah
- University of Calgary, Department of Trauma and Orthopaedic Surgery, 2500 University Drive NW, Calgary, Alberta, 2N 1N4, Canada
| | - Ian K. Lo
- University of Calgary, Department of Trauma and Orthopaedic Surgery, 2500 University Drive NW, Calgary, Alberta, 2N 1N4, Canada
| | - Marlis T. Sabo
- SCRUBS Research Unit, Cumming School of Medicine, University of Calgary, Canada
- Corresponding author. 4448 Front St SE, Calgary, AB, T3M 1M4, Canada.
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Lawrence RL, Zauel R, Bey MJ. Measuring 3D In-vivo Shoulder Kinematics using Biplanar Videoradiography. J Vis Exp 2021. [PMID: 33779606 DOI: 10.3791/62210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The shoulder is one of the human body's most complex joint systems, with motion occurring through the coordinated actions of four individual joints, multiple ligaments, and approximately 20 muscles. Unfortunately, shoulder pathologies (e.g., rotator cuff tears, joint dislocations, arthritis) are common, resulting in substantial pain, disability, and decreased quality of life. The specific etiology for many of these pathologic conditions is not fully understood, but it is generally accepted that shoulder pathology is often associated with altered joint motion. Unfortunately, measuring shoulder motion with the necessary level of accuracy to investigate motion-based hypotheses is not trivial. However, radiographic-based motion measurement techniques have provided the advancement necessary to investigate motion-based hypotheses and provide a mechanistic understanding of shoulder function. Thus, the purpose of this article is to describe the approaches for measuring shoulder motion using a custom biplanar videoradiography system. The specific objectives of this article are to describe the protocols to acquire biplanar videoradiographic images of the shoulder complex, acquire CT scans, develop 3D bone models, locate anatomical landmarks, track the position and orientation of the humerus, scapula, and torso from the biplanar radiographic images, and calculate the kinematic outcome measures. In addition, the article will describe special considerations unique to the shoulder when measuring joint kinematics using this approach.
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Affiliation(s)
- Rebekah L Lawrence
- Bone and Joint Center, Department of Orthopaedic Surgery, Henry Ford Health System
| | - Roger Zauel
- Bone and Joint Center, Department of Orthopaedic Surgery, Henry Ford Health System
| | - Michael J Bey
- Bone and Joint Center, Department of Orthopaedic Surgery, Henry Ford Health System;
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Haunschild ED, Gilat R, Fu MC, Condron N, Cole BJ. Biologics in shoulder and elbow pathology. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:1-6. [PMID: 37588635 PMCID: PMC10426570 DOI: 10.1016/j.xrrt.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
In recent years, orthobiologics have been of increasing clinical interest in the treatment of shoulder and elbow pathology. In some conditions, such as rotator cuff injury and lateral epicondylitis, there have been high-quality trials that support the use of platelet-rich plasma in reducing pain, restoring functionality, and improving clinical outcomes. However, as the numbers of both cellular-based biologics and the conditions being augmented by biologics continue to expand, there is a substantial need for high-quality investigations to support their routine use in most shoulder and elbow conditions. The purpose of this review is to summarize the current evidence of orthobiologics in the management of shoulder and elbow injury, as nonoperative treatment and as augments to operative treatment.
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Affiliation(s)
| | - Ron Gilat
- Midwest Orthopaedics at Rush, Chicago, IL, USA
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Cost-effectiveness analysis of arthroscopic surgery versus open surgery in rotator cuff repair. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.869051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Khazi ZM, Lu Y, Cregar W, Shamrock AG, Gulbrandsen TR, Mascarenhas R, Forsythe B. Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis. Arthroscopy 2021; 37:42-49. [PMID: 32721541 DOI: 10.1016/j.arthro.2020.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE III, Retrospective cohort study.
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Affiliation(s)
- Zain M Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A..
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - William Cregar
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
| | - Alan G Shamrock
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Trevor R Gulbrandsen
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Randy Mascarenhas
- McGovern Medical School, University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopedics at Rush, Chicago, Illinois, U.S.A
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Pierami R, Antonioli E, Oliveira I, Castro IQ, Manente F, Fairbanks P, Carrera EDF, Matsumura BA, Lenza M. Clinical outcomes and cost-utility of rotator cuff repair surgery by open and arthroscopic techniques: study protocol for a randomised clinical trial. BMJ Open 2020; 10:e043126. [PMID: 33372080 PMCID: PMC7772301 DOI: 10.1136/bmjopen-2020-043126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Rotator cuff injuries account for up to 70% of pain in the shoulder. However, there remains no consensus on the best surgical treatment for patients with rotator cuff injuries, in terms of the cost-effectiveness and cost-utility of open and arthroscopic methods for rotator cuff repair. The objective of this trial is to compare the efficacy, cost-effectiveness and cost-utility of open and arthroscopic procedures for rotator cuff repair. METHODS AND ANALYSIS The trial is a two-group, parallel-design, randomised controlled trial. A total of 100 patients with symptomatic rotator cuff lesions will be allocated in either open or arthroscopic technique in a 1:1 ratio, considering smoking (yes or no), lesion size (≤3 cm or >3 cm) and diabetes (present or absent) as stratification factors. All patients will be included in the same rehabilitation programme after the intervention. The primary outcome measure will be the Constant-Murley Score and the EuroQol-5D-3L score at 48 weeks postsurgery. Secondary outcomes include cost-effectiveness, cost-utility, pain, complications and clinical analysis, using the Simple Shoulder Test, Visual Analogue Pain Scale (VAS), integrity of the repair evaluated through MRI, and complications and failures of the proposed methods. For the cost-effectiveness analysis, we will use the VAS and the Constant-Murley Score as measures of effectiveness. For the cost-utility analysis, we will use the EuroQol-5D-3L as a measure of utility in terms of incremental cost per quality-adjusted life-years. ETHICS AND DISSEMINATION The study has been approved by the local research ethics committee of both institutions: Hospital Israelita Albert Einstein and Hospital Alvorada Moema/Hospital Pró-Cardíaco. The results will be published in a peer-reviewed, open access journal. TRIAL REGISTRATION NUMBER NCT04146987.
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Affiliation(s)
- Rafael Pierami
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Eliane Antonioli
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Isadora Oliveira
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Felipe Manente
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
| | - Paula Fairbanks
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
| | - Eduardo da Frota Carrera
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Bruno Akio Matsumura
- Departamento de Ortopedia, Grupo de Ombro e Cotovelo do Hospital Alvorada Moema, Sao Paulo, Sao Paulo, Brazil
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Mario Lenza
- Programa Locomotor, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Sao Paulo, SP, Brazil
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Abraham PF, Nazal MR, Varady NH, Gillinov SM, Quinlan NJ, Alpaugh K, Martin SD. The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears. J Shoulder Elbow Surg 2020; 29:2213-2220. [PMID: 32650076 DOI: 10.1016/j.jse.2020.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/13/2020] [Accepted: 06/22/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology. METHODS We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports. RESULTS Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying," or tearing). CONCLUSION DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.
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Affiliation(s)
- Paul F Abraham
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA.
| | - Mark R Nazal
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen M Gillinov
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
| | - Noah J Quinlan
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kyle Alpaugh
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, MA, USA
| | - Scott D Martin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Boston, MA, USA
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Is single stage capsular release and rotator cuff repair suitable for rotator tears with concomitant stiffness? J Orthop 2020; 21:496-499. [PMID: 32999537 DOI: 10.1016/j.jor.2020.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/31/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction It is common for patients with a rotator cuff tear to present with shoulder stiffness. There is no consensus on the acceptable level of stiffness at time of rotator cuff repair.We aim to determine if patients with stiffness undergoing rotator cuff repair and concomitant capsular release have different outcome than those with no stiffness undergoing rotator cuff repair alone. We hypothesize that patients with stiffness will not have poorer outcome than patients with no stiffness. Method We conducted a retrospective study of prospectively collected data for 47 patients who underwent arthroscopic rotator cuff repair under a single surgeon from 2010 to 2015. 25 patients were considered stiff (Stiff group) and 22 patients were considered to have no pre-operative stiffness (Non-stiff group).Range of motion and functional outcomes were collected preoperatively and post-operatively at two-years. Results There were no significant differences in gender distribution, age and cuff tear size between both groups. Pre-operatively, patients in the Stiff group had significantly poorer active range of motion (Forward flexion - Stiff 74.8° vs Non-stiff 100.2°, P = 0.001) and poorer function (Constant score - Stiff 23.5 vs Non-stiff 43.2, P < 0.001). Post-operatively, both groups of patients had increased range of motion, strength and reported lesser pain compared to pre-operation. There were no significant differences in post-operative outcomes between both groups. Conclusion Single-stage surgery combining capsular release and rotator cuff repair is effective for patients with stiffness as they are able to achieve similar results to those without shoulder stiffness.
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